Name:________________________________________________________________________

Address:_____________________________________________________________________

__________________________________________________Phone:(___)________________

Number of Adult Memberships: ______  ($40)

Number of Child Memberships: ______  ($25)

Children ages 6-13 may attend at the lower rates. Children 5 and below may 
attend free, provided they remain with a responsible adult at all times.

Total Amount Enclosed:  $________

     (Make Checks Payable to "Confluence" -- Do NOT send cash in the mail!)

The name I would like printed on my membership badge is:_____________________

Additional Attendee Names:              |   Their Badge should read:
                                        |
________________________________________|____________________________________
                                        |
________________________________________|____________________________________
                                        |
________________________________________|____________________________________
                                        |
________________________________________|____________________________________

I've included a SASE so that you can send me more information about:
 _
|_|   Art Show
 _
|_|   Being a Go-fer
 _
|_|   Dealers' Tables
 _
|_|   Program Book Ads
 _
|_|   Short Story Contest

Send this form, with check or money order made out to "Confluence", to:

Confluence 2011, P.O. Box 3681, Pittsburgh, PA 15230-3681

http://www.parsec-sff.org/confluence/index.html